Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth
MASSHEALTH
TRANSMITTAL LETTER AFC-10
November 2006
TO: Adult Foster Care Providers Participating in MassHealth
FROM: Beth Waldman, Medicaid Director
RE: Adult Foster Care Manual (Level II Service and Rate)
MassHealth pays participating adult foster care (AFC) providers for AFC ordered by a physician and provided to an eligible MassHealth member in a qualified setting. AFC services include assistance with activities of daily living, instrumental activities of daily living and other personal care, nursing services and oversight, and care management. Currently, MassHealth pays a single per diem rate (Level I rate) to participating AFC providers.
Effective December 1, 2006, MassHealth is introducing a new Level II AFC rate, which corresponds to a more intensive level of care provided to eligible MassHealth members who require the higher level of care.
This letter describes the Level II payment rate, conditions of payment, AFC provider responsibilities and care requirements, and billing requirements of the new rate. This letter also transmits a revised Subchapter 6, which identifies the service code-modifier combination required for billing for the Level II AFC rate.
Level II Payment Rates
Effective December 1, 2006, for a member who is determined to have met the clinical criteria for MassHealth coverage of AFC, an AFC provider may submit claims for payment at either the Level I or Level II AFC payment rate. Effective December 1, 2006, the Level II payment rate will be $82.02 per day.
Level II Conditions of Payment
The determination of the applicable payment rate for each member must be made upon admission, and must be reviewed annually and whenever there is a significant change in the memberís clinical status. Significant change is defined as a change in the memberís status that is not self-limiting (temporary), but permanent; impacts more than one area of the memberís health status; and requires interdisciplinary review or revision of the individualís AFC plan of care.
The AFC provider must bill MassHealth at the Level I AFC rate until the determination of service level indicates that the memberís condition requires Level II AFC.
The AFC provider must use the assessment form designated by MassHealth to document the need for Level I or Level II AFC and must maintain documentation in the memberís medical record that reflects the memberís level of AFC.
MassHealth pays for AFC at Level II if a member requires:
physical assistance with at least three of the following activities:
* bathing (full-body bath or shower);
* dressing, including street clothes and undergarments, but not just help with shoes, socks, buttons, snaps, or zippers;
* toileting, if the member is incontinent (bladder or bowel) or requires scheduled assistance or routine catheter or colostomy care;
* transferring, if the member must be assisted or lifted to another position;
* ambulating, if the member must be physically steadied, assisted, or guided one-to-one in ambulation, or is unable to self-propel a wheelchair appropriately without the assistance of another person; and
* eating, if the member requires constant supervision and cueing during the entire meal, or physical assistance with a portion or all of the meal;
or
physical assistance with two of the activities above and management of behaviors as defined below that require caregiver intervention:
* wandering: moving with no rational purpose, seemingly oblivious to needs or safety;
* verbally abusive behavioral symptoms: threatening, screaming, or cursing at others;
* physically abusive behavioral symptoms: hitting, shoving, or scratching;
* socially inappropriate or disruptive behavioral symptoms: disruptive sounds, noisiness, screaming, self-abusive acts, disrobing in public, smearing or throwing food or feces, rummaging, repetitive behavior, or causing general disruption; or
* resisting care.
AFC Provider Responsibilities and Care Requirements for Level II AFC
Clinical Assessments. For Level II AFC, the AFC providerís multidisciplinary team must complete the Minimum Data Set Ė Home Care (MDS-HC) or the Comprehensive Data Set (CDS), and all other applicable assessments to support the claim for Level II payment. Assessments must be made upon admission, and must be reviewed annually and whenever there is a significant change the memberís clinical status.
AFC Plan of Care. For individuals needing and receiving Level II AFC, the registered nurse must review and update the memberís plan of care at least quarterly and whenever there is a significant change in the memberís clinical status.
On-Site Visits. When an individual has been determined to require Level II services, the registered nurse and care manager must visit the member, at the site where caregiver services are delivered, on a monthly basis or more often as the memberís condition warrants. If the individual is determined to require Level II AFC on admission, the registered nurse must perform on-site visits on the day of admission and weekly for the first 30 days of AFC.
Documentation. The nurse and care manager must complete a progress note for each site visit or encounter with the member and whenever there is a significant change in the memberís clinical status.
AFC Caregivers. For Level II AFC, certain relatives of a MassHealth member may serve as that memberís AFC caregiver; but those relatives may not include the memberís spouse, parent or adoptive parent if the member is a minor child, or any legally responsible relatives who are prohibited from serving as personal caregivers under federal Title XIX rules.
Number of Members at Level II. The AFC provider must ensure that the qualified AFC caregiver is not serving more than a total of three persons, no more than two of whom require Level II AFC, in the qualified setting, regardless of care provided or source of payment.
Billing Requirements
AFC providers seeking payment for AFC, including Level II AFC, must bill with the approved service code and modifiers listed in Subchapter 6 of the Adult Foster Care Manual. Effective December 1, 2006, AFC provided at Level II must be billed with Service Code S5140 with modifier TG (AFC Level II).
This letter transmits a revised Subchapter 6. The revisions include the service code-modifier combination required for Level II AFC.
Questions
If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Adult Foster Care Manual
Pages 6-1 and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Adult Foster Care Manual
Pages 6-1 and 6-2 ó transmitted by Transmittal Letter AFC-9
Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
6. Service Codes and Descriptions
Page
6-1
Adult Foster Care Manual
Transmittal Letter
AFC-10
Date
12/01/06
601 Service Codes and Descriptions
Service
Code Modifier Service Description
S5140 Foster care, adult; per diem (Adult foster care personal care and administration; per diem, Level I)
S5140 TG Foster care, adult; per diem (Adult foster care personal care and administration; per diem, Level II)
S5140 TF Foster care, adult; per diem (Adult foster care short-term alternate placement; per diem for caregiver)
Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
6. Service Codes and Descriptions
Page
6-2
Adult Foster Care Manual
Transmittal Letter
AFC-10
Date
12/01/06
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